MEDICARE: EVERINGHAM CLINIC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1477621050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERINGHAM CLINIC PC

Provider Business Mailing Address
First Line	:	12100 HURON RIVER DRIVE
Second Line	:
City	:	ROMULUS
State	:	MI
Zip	:	48174-1119
Country	:	US
Telephone Number	:	734-941-1070
Fax Number	:	734-941-1763

Provider Business Practice Location Address
First Line	:	12100 HURON RIVER DRIVE
Second Line	:
City	:	ROMULUS
State	:	MI
Zip	:	48174-1119
Country	:	US
Telephone Number	:	734-941-1070
Fax Number	:	734-941-1763

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CRAIG J EVERINGHAM
Credential	:	DO
Telephone Number	:	734-941-1070

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	02/20/2014

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